Blood pressure should be monitored closely in individuals with high blood pressure discontinue the combined hormonal contraceptive if blood pressure rises significantly. The incidence of hypertension increases with increasing concentration of progestin. An increase in blood pressure has been reported in women taking CHCs, and this increase is more likely in older women and with extended duration of use. Because of their association with elevations in blood pressure, CHCs should be used cautiously in patients with mild to moderate hypertension or kidney disease use is contraindicated in patients with uncontrolled or severe hypertension or hypertension with vascular disease. After a CHC is discontinued, the increased risk of thromboembolic disease gradually disappears. Levonorgestrel ethinyl estradiol should be discontinued if an arterial or venous thromboembolic event occurs.
Pre-existing high blood pressure, kidney disease, hypercholesterolemia, diabetes with vascular disease, or patients who are morbidly obese may also increase risk. The risk of arterial thromboses, such as stroke and myocardial infarction, is especially increased in women with other risk factors for these events. Preliminary data from a large, prospective cohort safety study suggests that the risk is greatest during the first 6 months after initially starting CHC therapy or restarting (following a break from therapy 4 weeks or more) with the same or different combination product. The overall risk of venous thromboembolism in women using combined hormonal contraceptives has been estimated to be 3 to 9 per 10,000 woman-years. Some data suggest that non-cyclic exposure may also increase thromboembolic risk. In addition, certain progestins may increase thromboembolic risk. A positive relationship between estrogen dosage and thromboembolic disease has been demonstrated, and oral products containing 50-mcg ethinyl estradiol should not be used unless medically indicated. Therefore, CHCs are contraindicated in women over the age of 35 years who are tobacco smokers. Risk is especially high for female smokers more than 35 years of age or those who smoke 15 or more cigarettes per day. Because tobacco smoking increases the risk of thromboembolism, DVT, myocardial infarction, stroke and other thromboembolic disease, patients receiving CHCs are strongly advised not to smoke. Combined hormonal contraceptives are also generally contraindicated in women who have thrombogenic valvular or thrombogenic rhythm diseases of the heart (e.g., subacute bacterial endocarditis with valvular disease, or atrial fibrillation), or known inherited or acquired hypercoagulopathies (e.g., protein S deficiency, protein C deficiency, Factor V Leiden, prothrombin G20210A mutation, antithrombin deficiency, antiphospholipid antibodies).
Combined hormonal contraceptives have been associated with thromboembolism such as deep venous thrombosis (DVT) and pulmonary embolism (PE). Atrial fibrillation, cardiac disease, cerebrovascular disease, coronary artery disease, coronary thrombosis, edema, endocarditis, hypercholesterolemia, hypertension, myocardial infarction, protein C deficiency, protein S deficiency, renal disease, stroke, thromboembolic disease, thromboembolism, thrombophlebitis, tobacco smoking, valvular heart diseaseĬombined hormonal contraceptives (CHCs) are contraindicated in patients with a current or past history of stroke, cerebrovascular disease, coronary artery disease, coronary thrombosis, myocardial infarction, thrombophlebitis, thromboembolism or thromboembolic disease, or valvular heart disease with complications.
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